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Wednesday, 3 August 2011

Smoking bans threaten mental health: Opinion, Australia

This writer asks why comprehensive smoking bans are imposed on mentally ill people, when at least at this point in our history nobody would think it right to impose such a comprehensive ban on the rest of the community. Both the circumstances of a person's incarceration in mental health facilities and the fact that they may not get home for a period of days, weeks or months, to say nothing of their existing mental anguish and the effects of any medication, make somebody's stay in a mental health facility possibly one of the least suitable times to deprive them suddenly of nicotine and expect them to get by on patches at best.

There do seem to be people out there in the caring profession who find the opposite and who knows but they may be most sincere in their views. But bringing in a comprehensive ban that will force psychologically disturbed people to withdraw suddenly from nicotine would be controversial even if implemented in a single unit. The current trend is for health departments to encourage if not legislate for the provision of comprehensive smoke-free mental health service, affecting all units everywhere. People who run these departments are not medics, they are officials, who seem to be motivated by targets and ideologies dressed up as care for patients.

The comments on this story are instructive too, especially the one that points out that 'nicotine replacement is not an alternative to smoking, it's an aid to give up smoking'. In the eyes of tobacco control, nicotine replacement is a form of 'harm reduction': i.e. anything is better than smoking (as long as it's not made in China with cartridges of course) and we'll give you nicotine patches because you really want to give up smoking, don't you – most smokers do, after all! One reader says:

We should not be allowing or encouraging people to utilise pathological coping mechanism when they are facing a crisis. When alcoholics and heroin addicts are admitted we provide healthier alternative and encourage them to reduce their dependence.

But this is a false parallel. No one is admitted to psychiatric care because he or she is a smoker. Drug and alcohol abuse signify addictions of a completely different order from a nicotine habit. There is no reason that any patient should be compelled to give up smoking. Allowing smoking areas need not undermine the ward experience for everyone else. It's just a matter of will.

9 comments:

I was appalled at the comments by Matt under the NZ article.So it's difficult to get patients to quit smoking. So they will have withdrawal symptoms. They might react violently and have to go into isolation. Tough. You're saying that because quitting is difficult we shouldn't bother? Baloney.

The ultimate benefits of quitting far outweigh the initial challenges. If they have a freak out they can go into a locked room, they can scream, shout and cry, they can throw their mattress at the wall. They won't die and once withdrawal is over it's over.

He doesn't seem to be aware enough to understand the consequences of what he is saying.

Interesting piece DP: I like this: 'A survey of the effects of a smoking ban at Britain's most secure psychiatric hospital, Rampton, though for the most part endorsing the ban, could not ignore disturbing trends which appear to raise doubts about the therapeutic merits of the ban. A comparison of violent incidents and the need to remove patients to 'seclusion' before and after the ban showed a dramatic increase among pre-ban smokers. Self harm and aggressive incidents increased by 25% and resort to seclusion doubled. (These rates would likely be worse at other hospitals: Rampton is unusually well resourced). Unsurprisingly, British Mental Health Foundation surveys have shown significant staff concern that smoking bans are a drain on resources (BBC Online 2009 (2009-06-21)). There is every reason to think the ban will require extra resources in New Zealand too, resources which could go into patient care.' He knows where to look for his studies: the antis just tell us that they have been no adverse effects, which is scarcely credible.

And this: 'There is good evidence that some mental illnesses are associated with compulsion and disempowerment, of the sort that the ban is likely to generate in spades, that quitting smoking is stressful, and that depression is associated with a failure to quit smoking. All of that might suggest that compulsory smoking bans would be bad, rather than good, for mental health.'

The results in the abstract present a view that everything is ok except for the sterile "only one significant comparison". It may not be the study or the details (which are PPV) may contain the info refered to in the NZ article."Of the 298 patients in the hospital for the evaluation period, 72.8% were smokers before the ban. There were no significant differences in rates of seclusion before and after the ban and only one significant comparison (P = 0.01) showed an increase in untoward incidents for smokers. There were no significant increases in the use of psychotropic medication after the ban. "

It is worth reading the comments of Sajid Muzaffar as he questions the ethics around this issue.

Promotion of a smoking free life style is laudable and from public health point of view a desirable policy but use of the powers of Mental Health Act to enforce such a policy is neither helpful to patient management nor ethically defensible.

I was a non-smoker for 6 years before I ended up on my local acute psychiatric ward last year.(first admission of many)

Until local acute and long-term psychiatric care becomes just that- care as opposed to containment then the proposed smoking ban will just serve to further punish those who are frankly being punished enough by poor services and poor mental health- the focus is in the wrong area as usual.

The long term health of the mentally ill could be far better served by proper organisation, communication and investment in MH services, a nicotine patch can do little to help those whose lives have fallen apart due to mental illness.

Sure my lungs have deteriorated since I took up smoking again but not as much as my quality of life has deteriorated since I became mentally ill and was left at the mercy of local mental health "care".

mentalpoliticalparent – Thanks for your comment. It is now axiomatic that giving up smoking is the best thing you can do for your health. But this has no reference to people's preferences. People are entitled to make choices, as you have done.